B738, vicinity Cork Ireland, 2006
From SKYbrary Wiki
|On 4 June 2006, a Boeing 737-800 being operated by Ryanair on a passenger flight from London Stansted to Cork became too high to land off a day visual approach and requested a right hand orbit to reposition. This positioning was flown too close to terrain with TAWS alert triggered prior to a second approach to a successful landing.|
|Actual or Potential
|Controlled Flight Into Terrain (CFIT), Human Factors|
|Type of Flight||Public Transport (Passenger)|
|Intended Destination||Cork Airport|
|Take off Commenced||Yes|
|Flight Phase||Missed Approach|
|Location - Airport|
|Airport vicinity||Cork Airport|
|Tag(s)||Approach not stabilised,|
Event reporting non compliant
Vertical navigation error
Procedural non compliance
|Safety Net Mitigations|
|Damage or injury||No|
|Causal Factor Group(s)|
On 4 June 2006, a Boeing 737-800 being operated by Ryanair on a passenger flight from London Stansted to Cork became too high to land off a day visual approach and requested a right hand orbit to reposition. This positioning was flown too close to terrain with GPWS/TAWS alert triggered prior to a second approach to a successful landing.
The Irish AAIU was not advised of this event at the time and did not find out about it until contacted by the Operator 9 days later at which point an Investigation was commenced. It was established that the aircraft commander, with good aircraft type experience, had been PF.
The break to the right off the first approach was found to have initially been made at at the prescribed minimum manoeuvring altitude of 1100 feet QNH (equivalent to 600 feet aal) but altitude was then gradually lost during this orbit. The lowest altitude recorded was 553 feet QNH (51 feet aal) although, because some of the terrain around the airport was considerably lower than the airport elevation, the actual minimum height above terrain recorded by the radio altimeter was 425 feet agl. When it became visually obvious to the flight crew that the aircraft was well below the appropriate vertical approach profile, a climb was initiated to a height from which a safe landing was ultimately effected.
The Investigation noted that:
“The two subject approaches raise questions for standard Crew Resource Management Courses pursued by the wider aviation industry, in general. In particular, to what degree can the PNF assert himself or herself when the PF is not responding to or disregarding inputs from the right hand seat? The ‘experience gradient’ between the PF and the PNF in this instance was steep, but not unusual in day-to-day operations, and may have been a contributory factor in the PF’s attitude to the PNF. Regardless, the PNF did endeavor to comply with CRM principles as trained. His inputs had little effect. However, this is not to excuse the aberrant deviation from the Operator’s SOPs’s, which require that the aircraft be fully stabilized in the landing profile by 500 ft agl on a visual approach, and adherence to CRM procedures by the PF.”
It was concluded that:
“this serious incident was precipitated by the PF not adhering to the Operators explicit SOP’s in the two approaches to (the runway in use) and also by not conforming to established CRM principles in relation to the PNF.”
The Final Report of the investigation was published on 30 January 2007 and may be seen in full at SKYbrary bookshelf: AAIU Synoptic Report No: 2007-002
No Safety Recommendations were made.